Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3303

2. Registrant Information.

Registrant Reference Number: 2013-10185

Registrant Name (Full Legal Name no abbreviations): Alberta Government/ Agriculture and Rural Development

Address: 304, JG O'Donoghue Building, 7000-113th. Street

City: Edmonton

Prov / State: Alberta

Country: Canada

Postal Code: T6H-5T6

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

03-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

31-MAY-13

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 18300      PMRA Submission No.       EPA Registration No.

Product Name: Sodium Monofluoroacetate Predacide (1080)

• Active Ingredient(s)
  • SODIUM MONOFLUOROACETATE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: N/A

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

An acreage owner/sheep producer in the County of (name) applied the product to deal with an ongoing coyote problem. The product was issued to the land owner and subsequently applied in accordance with all of the necessary protocols. The product was placed in ten (10) chicken heads and strategically placed on their property while satisfying all of the required set back distances with warning signs posted. Neighbors dog strayed and ingested the product and subsequently died.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

It is believed that one tablet of the product was used on the chicken head. the dog ingested the product that resulted in undetermined symptoms that resulted in its death

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

It should me mentioned that the product was placed in nine other locations on the land owners property without any similar incidents.